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Physician health programs (PHPs) have demonstrated efficacy, but their mechanism of influence is unclear. This study sought to identify essential components of PHP care management for substance use disorder (SUD), and to assess whether positive outcomes are sustained over time.Physicians with DSM-IV diagnoses of Substance Dependence and/or Substance Abuse who had successfully completed a PHP monitoring agreement at least 5 years before the study (N = 343) were identified as eligible. Of the 143 (42%) that could be reached by phone, 93% (n = 133; 86% male) completed the anonymous online survey.Virtually all PHP program components were rated as being at least "somewhat helpful" in promoting recovery, with the plurality of respondents rating almost all components as "extremely helpful." The top-rated components were: signing a PHP monitoring agreement, participation in the PHP, formal SUD treatment, and attending 12-step meetings, with each receiving a mean rating of at least 6.2 out of 7. Notably, 88% of respondents endorsed continued participation in 12-step fellowships. Despite the significant financial burden of PHP participation, 85% of respondents reported they believed the total financial cost of PHP participation was "money well spent."Components of PHP monitoring were viewed as acceptable and helpful to physicians who completed the program, and outcomes were generally sustained over 5 years. More studies are needed to confirm these preliminary findings.This study documents the perceived cost-benefit of participation in a PHP among a small sample of program completers.

The prevalence rate of addiction among physicians is similar to the general population, with approximately 10% to 12% of U.S.-based physicians developing substance use disorders (SUDs) during their lifetimes. To address this public health concern, physician health programs (PHPs) have been created to facilitate the early identification, evaluation, treatment, and monitoring of physicians. Although a number of published studies provide outcome information from PHPs, there has been no comprehensive review of the related literature. The objective of this narrative review is to summarize the treatment outcomes, including treatment types, rates of relapse, rates of contract completion or extension, as well as licensure and work status rates of a nationally representative physician cohort and related subpopulations from a single dataset. Based on the studies included in this review, our findings reveal that physicians who completed their PHP contracts have more favorable treatment outcomes than members of the general population who receive mainstream treatment. In addition, our review describes unique features of physician rehabilitation facilitated by PHPs. However, further prospective research is needed to ensure a standardized and comparable dataset and facilitate performance improvement.

The objective of this study was to compare outcomes of psychiatrists and nonpsychiatrist physicians enrolled in state physician health programs for substance use disorders.The study used the data set from a five-year, longitudinal cohort study of 904 physicians, including 55 psychiatrists, with diagnoses of substance abuse or dependence consecutively admitted to one of 16 state physician health programs between 1995 and 2001.There was a higher proportion of women among psychiatrists than among other physicians, but there were no other significant differences between the cohorts. Five-year outcomes were similar between psychiatrists and the other physicians, with at least 75% of psychiatrists continuing their medical practice after five years of monitoring and treatment.Psychiatrists were not overrepresented compared with other physician groups and had similar clinical outcomes at the five-year follow-up. Physician health programs appeared to be effective treatment programs for psychiatrists with substance use disorders.

In this issue of the Journal of Graduate Medical Education, Bell and colleagues1 address the question of prevalence of drug testing for residents and medical students. The authors found that, within a sample of family medicine residencies, most programs performed pre-employment testing of residents but not medical students. In response to positive drug tests, programs were equally likely to deny a residency position or provide a position after rehabilitation. This paper adds to reports on this important topic. Data surrounding physician drug testing are sparse, and scientific inquiries like these are sorely needed. Up to one-third of physicians will be impaired at some point in their lives, either through drugs, alcohol, or mental health issues.2 The best evidence we have suggests that physicians have a lifetime prevalence for substance use disorders of 10% to 15%, a rate similar to that of the general population.3 Thus, physicians are not immune to the problem of drug abuse, either in their home life or in their care for patients. We have previously described a framework for protecting patients from impaired physicians that involves early identification through routine drug testing and rehabilitation of the potentially impaired individual.4 In other high-risk industries that involve public safety, this type of testing is routine and well accepted.5,6 Drug testing of physicians is a topic that has drawn recent attention and political controversy. On November 4, 2014, Californians voted down a ballot measure, Proposition 46, the Medical Malpractice Lawsuits Cap and Drug Testing of Doctors Initiative.7 In addition to other components, this measure would have required drug testing of physicians after an adverse event. Although we support the framework and there is empirical evidence for physician drug testing, the California measure was ill-conceived, and the physician drug testing component was likely a cover to increase the medical malpractice limits within the state. Still, the measure makes it apparent that a public desire for patient protection and physician drug testing exists. Bell and colleagues1 established the prevalence of drug testing among training programs, with family medicine as the model. Although it is reassuring that nearly 70% of programs perform pre-employment testing, one-third of programs do not. Moreover, only about 10% of programs perform some amount of random drug testing. Although pre-employment testing is important, periodic random testing adds important information, improves the performance of pre-employment testing, and is routinely performed in other safety-sensitive industries (eg, aviation, nuclear regulatory, railway systems, criminal justice, and others).8 In this study, the health system rather than the residency program initiated the majority of the drug testing. Indeed, it is unclear whether many program directors were aware of the drug testing policies of the health systems in which their programs function. Perhaps health care systems have the infrastructure and policies in place to deal with testing results. Health care systems are responsible for the delivery of health care, so they are ultimately responsible for their employees, among them, medical students and residents. Although most residency programs stated they used pre-employment drug testing, they did not describe how they defined this testing. Except for marijuana, it is unclear what type of drug test panel was used. The conventional National Institute on Drug Abuse 5 drug test panel is limited and inadequate to detect today's substances of abuse.9 Health care provider organizations should standardize the selection of the drug test panels to match the population being screened. Opponents of drug testing express concern over the accuracy of testing. Although the potential for false positives exists, confirmatory testing using gas chromatography-mass spectrometry yields a nearly 100% accurate result (defined as a correlation between measured and known concentration).10 The risk for false positive results is further reduced by independent testing using split test samples, review by a medical review officer, and an in-depth evaluation of the individual when appropriate. Other industries have used these processes for years.11 Opponents of drug testing also cite the costs of testing programs. The individual cost of urine drug screens, with test panels that include most drugs used by unlicensed professionals, are low ($15 to $50 per urine sample).12 In addition to the cost for the test panel, additional costs include sample collection (∼$30 to $40 per sample), medical review officer ($50 to $84 per hour), quality control samples (∼$30 per sample), confirmatory independent gas chromatography-mass spectrometry testing (∼$25),13 and program administration (varies). There are economies of scale for these costs. An anesthesiology program that included both pre-employment and random drug testing, using more advanced and expensive testing panels, estimated their costs to be about $50,000 per year. These costs are balanced against the costs of impaired physicians and the benefits of drug testing, including reduced absenteeism, increased productivity, and decreased accidents.13 This last benefit in health care is probably most important as it involves not only a financial cost but also the health and lives of our patients. Finally, opponents of drug testing question the efficacy of drug testing for detecting and preventing drug abuse. The argument is that “physicians would not put their patients at risk by coming to work impaired, so why bother testing for drugs/alcohol.” This argument has 2 shortcomings. First, the best evidence suggests physician substance use occurs at a rate similar to that of the general population. Second, although physician professionalism does uphold their fiduciary relationship to their patients (a physician's practice is the last place impacted by their impairment), chemical dependency, as a mental illness, will, if not detected early, ultimately undermine a physician's practice and patient safety.14 From an effectiveness perspective, published results in health care suggest that programs are able to detect and deter drug use. For pre-employment testing at large urban medical centers, between 4% and 10% of samples are positive.15,16 Among anesthesiology residents at 1 program, approximately 1% were positive.17 In addition to detection of impaired physicians, an important benefit of drug testing is the potential deterrent effect. Some colleagues might seek assistance or employment elsewhere, knowing that they will be drug tested. Among health care workers at a large urban medical center, positive drug tests fell from 10.8% to 5.8% after a formal pre-employment testing program was put in place.15 In the anesthesiology program previously cited, pre-employment and random drug testing led to a decrease in positive samples from 1% to 0%.17 More data in this area are needed. Although possession of marijuana remains illegal under federal law, recent legalization of marijuana in some states adds a layer of complexity to the issue of drug testing. In many ways, marijuana, in those states where it is legal, might be viewed similarly to alcohol use. Whether or not marijuana is legal, providing patient care while impaired puts patients at risk; therefore, signs of impairment should trigger the need for drug testing. States that have laws regulating the use of marijuana often administer blood tests for tetrahydrocannabinol (THC) to determine a driver's level of impairment. In both Colorado and Washington state, drivers who are found to have THC in their bloodstream at a level of ≥5 ng/mL are considered “under the influence,” and may be subject to penalty.18,19 This practice might be acceptable in the medical practice setting as well. In summary, Bell and colleagues1 have added to the understanding of drug use and testing among physicians in the United States. Studies like this are needed in order to inform our policies around management of physician impairment and to identify areas that require further attention. These efforts help to improve the safety of our patients and the health of our colleagues.

Author(s): Rose, John; Campbell, Michael; Skipper, Gregory | Abstract: Introduction: Emergency physicians (EPs) are reported to have a higher rate of substance use disorder (SUD) than most specialties, although little is known about their prognosis. We examined the outcomes of emergency physician compared to other physicians in the treatment of substance use disorders in Physician Health Programs (PHP).Methods: This study used the dataset from a 5-year, longitudinal, cohort study involving 904 physicians with diagnoses of SUD consecutively admitted to one of 16 state PHPs between 1995 and 2001. We compared 56 EPs to 724 other physicians. Main outcome variables were rates of relapse, successful completion of monitoring, and return to clinical practice.Results: EPs had a higher than expected rate of SUD (odds ratio [OR] 2.7 confidence interval [CI]: 2.1–3.5, p,0.001). Half of each group (49% of EPs and 50% of the others) enrolled in a PHP due to alcohol-related problems. Over a third of each group (38% of EPs and 34% of the others) enrolled due to opioid use. During monitoring by the PHPs, 13% of EPs had at least one positive drug test compared to 22% of the other physicians; however, this difference was not significant (p¼0.13). At the end of the 5-year follow-up period, 71% of EPs and 64% of other physicians had completed their contracts and were no longer required to be monitored (OR 1.4 [CI: 0.8-2.6], p ¼ 0.31). The study found that the proportion of EPs (84%) continuing their medical practice was generally as high as that of other physicians (72%) (OR 2.0 [CI: 1.0–4.1], p ¼ 0.06).Conclusion: In the study EPs did very well in the PHPs with an 84% success rate in completion and return to clinical practice at 5 years. Of the 3 outcome variables measured, rates of relapse, successful completion of monitoring, and return to clinical practice, EPs had a high rate of success on all variables compared to the other physician cohort. These data support the conclusion that EM physicians do well following treatment of SUD with monitoring in PHPs and generally return to the practice of emergency medicine. [West J Emerg Med. 2014;15(1):20–25.]

Background: Monitoring alcohol use is important in numerous situations. Direct ethanol metabolites, such as ethyl glucuronide (EtG), have been shown to be useful tools in detecting alcohol use and documenting abstinence. For very frequent or continuous control of abstinence, they lack practicability. Therefore, devices measuring ethanol itself might be of interest. This pilot study aims at elucidating the usability and accuracy of the cellular photo digital breathalyzer (CPDB) compared to self-reports in a naturalistic setting. Method: 12 social drinkers were included. Subjects used a CPDB 4 times daily, kept diaries of alcohol use and submitted urine for EtG testing over a period of 5 weeks. Results: In total, the 12 subjects reported 84 drinking episodes. 1,609 breath tests were performed and 55 urine EtG tests were collected. Of 84 drinking episodes, CPDB detected 98.8%. The compliance rate for breath testing was 96%. Of the 55 EtG tests submitted, 1 (1.8%) was positive. Conclusions: The data suggest that the CPDB device holds promise in detecting high, moderate, and low alcohol intake. It seems to have advantages compared to biomarkers and other monitoring devices. The preference for CPDB by the participants might explain the high compliance. Further studies including comparison with biomarkers and transdermal devices are needed.

Objectives There is little published evidence on how well family medicine physicians (FMPs) with substance use disorder (SUD) perform in Physician Health Programs (PHPs). We examined outcomes for FMP compared with non-FMP physicians. Methods This study utilized data from a 5-year, longitudinal, cohort study involving 904 physicians with diagnoses of SUD consecutively admitted to one of 16 state PHPs between 1995 and 2001. We compared 175 FMPs to 687 other physicians. Outcome measures were relapse, successful completion of monitoring contract at 5 years, and licensed and employed at 5 years. Results Of the 3 outcome variables measured: relapse, successful completion of monitoring contract at 5 years, and licensed and employed at 5 years, FMPs had similar rates of success on all variables except monitoring contract completion at 5 years when compared with the other physician cohort. Conclusions In this study, FMPs with SUD do as well as other physicians in PHPs at 5 years. However, FMPs were less likely to complete the monitoring contract at 5 years as compared to the other physician cohort.

Alcohol and drug abuse and addiction among medical students have been reported extensively. This is an important topic because substance abuse can lead to impairment, which affects the well-being of many, including medical students, and because it compromises physician competency. Education and clinical training regarding substance use disorders (SUDS) has been severely neglected, especially in relation to their incidence, not only among health professionals but also among patients. Students know little about SUDS and little regarding identifying a colleague in trouble. This article presents a case of a peer medical student intervention with a successful outcome as a proximate result of a brief educational program for medical students and argues for more education regarding SUDS, professional impairment, and how to deal with a peer who has a problem. To our knowledge, peer medical student intervention for a fellow student addicted to alcohol or drugs has never been reported in the English language.

Aims To compare treatment outcome among substance dependent physicians enrolled in a physician health program (PHP) who have a history of alcohol use only, any opioid use, or non-opioid drug use, in order to determine whether the distinctive PHP system of care management is as effective for individuals with opioid use disorders as for those with alcohol or other drug use disorders. Methods A 5-year, retrospective chart review, intent-to-treat analysis was conducted for all physicians admitted to 16 physician health programs (N = 702; 85.5% male; age range = 24–75). Analyses compared treatment outcomes for participants based upon their substance(s) of abuse [i.e., 1) “Alcohol Only” (n = 204), 2) “Any Opioid” with or without alcohol use (n = 339), and 3) “Non-Opioid” drug use with or without alcohol use (n = 159)]. Results In this sample, 75–80% of physicians across the three groups never tested positive for alcohol or drugs during their extended care management period with random drug testing. This included physicians with opioid dependence who did not receive opioid substitution therapy (OST). Of the 22.1% of physicians who had a positive test, two thirds (i.e., 14.5% of the total sample) had just one positive test, and only one third (i.e., 7.6% of the total sample) had more than one positive test. These results were similar in all three groups. Conclusions These results indicate that individuals with opioid use disorders who are managed by PHPs can achieve long-term abstinence from opioids, alcohol, and other drugs without OST through participation in abstinence-based psychosocial treatment with extended, intensive care management following discharge.

This article summarizes content proceedings of a symposium held at the 2004 International Society for Biomedical Research on Alcoholism Congress in Mannheim, Germany. The chairs were Boris Tabakoff and Friedrich M. Wurst. The presentations were (1) Genetic associations with alcoholism and affective disorders, by Paula Hoffman; (2) Proteomic analysis of blood constituents in alcoholism, by Boris Tabakoff; (3) Contrasts between the responses of GGT and CDT to high alcohol intake, and a test of their combined use, by John Whitfield; (4) Direct ethanol metabolites such as ethyl glucuronide, fatty acid ethyl esters, phosphatidylethanol and ethyl sulfate: a new line of sensitive and specific biomarkers, by Friedrich Martin Wurst; and (5) Genetic studies of alcoholism subtypes in a Han Taiwanese population, by Ru-Band Lu.

Aims Current biological state markers remain suboptimal with regard to sensitivity and specificity for monitoring recent alcohol consumption in various settings. Furthermore, these biomarkers can be influenced by age, gender and a variety of substances and non-alcohol-associated diseases and do not cover fully the time axis for alcohol intake. Ethyl glucuronide (EtG) is a non-volatile, watersoluble, stable, direct metabolite of ethanol that can be detected in various body fluids, tissues and hair. Shortly after the consumption even of small amounts of ethanol, EtG becomes positive. It can detect ethanol intake up to 80 hours after the complete elimination of alcohol from the body, covering a unique and important time spectrum for recent alcohol use. EtG seems to meet the need for a sensitive and specific marker to elucidate alcohol use not detected by standard testing. Design, setting, participants, methods and findings The literature was reviewed with a focus on possible diagnostic and therapeutic applications, currently available methods and future perspectives. To date, more than 4000 samples of body fluids, tissues and hair from approximately 1500 individuals have been assessed. Conclusions The data suggest that EtG is a useful tool in numerous settings, including alcohol and drug treatment (to detect lapse/relapse and for motivational feedback), in safety sensitive work settings where use is dangerous or in other settings where alcohol use may be risky (e.g. such as driving, work-place, pregnancy or monitoring physicians or other professionals who are in recovery and working) or for resolving forensic questions. If the question of recent alcohol consumption has to be answered in a binary way (yes/no), such as for determining lapses, the use of EtG in urine is among the preferred tests. The use of this marker alone and complementary with other biological state markers and self-reports is expected to lead to significant improvement in treatment outcome, therapy efficacy and cost reduction.

The aim of this study was to estimate the prevalence of cannabis use among Swiss students and to assess their attitudes regarding health and safety issues associated with drug use.After a workshop, 173 students (23.1% male, 75.7% female; 44.4% age 16, 43.8% age 17 and 11.8% age 18) from a Swiss school were surveyed by questionnaire.59.3% (n=103) of all participants had tried cannabis, and 30.1% of those who reported cannabis use had consumed more than 100 joints. Of those 103 students with cannabis experience, 6.8% rated the risk of cannabis-related psychic effects as low, and 9.8% were not concerned about driving under the influence of cannabis. In cases of heavy cannabis use, the chance of increased tobacco, alcohol or other drug use is higher than for those with less or no cannabis use at all (odds ratios of 4.33-10.86).This paper deals primarily with cannabis prevalence data in adolescents from previous studies and sources, and shows that our findings deviate significantly - and surprisingly - from past research. Our data from a school survey indicates higher cannabis use than data from official drug policy studies. Additionally, our data shows that the students' self-reported attitudes towards health and safety issues were mostly realistic. The examination of methodological issues that might impact prevalence estimates should be added to the cannabis literature.

Chemical dependence among health professionals is a significant problem, with a lifetime prevalence of approximately 10-15%. A physician who undertakes the challenge of treating other physicians for chemical dependence must have firm boundaries, and must be willing to provide extra time and patience. Denial of symptoms, countertransference and other pitfalls have been cited as prominent potential problems. Although there is evidence that physicians in general have excellent outcomes following chemical dependence treatment, mismanagement can be disastrous. Standards are suggested for centers that wish to treat this population.

Objectives To test the robustness of the findings of previous studies in a large aggregated sample regarding (a) the impact of a patient's suicide on therapist's distress; (b) identify a potential subgroup of therapists needing special postvention; (c) and assess potential differences in overall distress between professional groups and at different levels of care. Methods A questionnaire, characterizing the therapists, their reactions and the patients, had been sent out to 201 psychiatric hospitals in Germany providing different levels of care. Aggregated data from previous studies have been used. Results In 39.6% of all cases, therapists suffer from severe distress after a patients' suicide. The global item "overall distress" can be used as an indicator to identify a subgroup of therapists that might need individualized postvention. No significant difference in overall distress experienced was observed between professional groups and at different levels of care. Conclusion Our data suggest that identifying the severely distressed subgroup could be done using a visual analogue scale for overall distress. As a consequence, more specific, individualized and intensified help could be provided to these professionals, helping them to overcome distress and thereby ensuring delivery of high quality care to the patient.

Objective Surveys assessing alcohol use among physicians have most commonly employed the Alcohol Use Disorders Identification Test (AUDIT) or the AUDIT-C, the most common short version of the AUDIT. As with other screeners, prevalence estimation is dependent on the accuracy of the test as well as choice of the cutoff value. The aim of the current study is to derive more precise prevalence estimates of alcohol problems in physicians by correcting for false-positive and false-negative results. Method In the context of a survey, the AUDIT was sent out via email or standard postal service to all 2484 physicians in Salzburg, Austria. A total of 456 physicians participated. A published correction formula was used to estimate the real prevalence of alcohol use problems. Results Applying a cutoff of 5 points for the AUDIT-C, 15.7% of female and 37.7% of male physicians screened positive. Use of a correction based on general population data and the sensitivity and specificity of the AUDIT-C resulted in much lower prevalence rates: 4.0% for female and 9.5% for male physicians. Using the full AUDIT, 19.6% of the female physicians and 48% of the male physicians were screened positive. Using the correction, the estimated prevalence rates for females and males were 6.3% and 15.5%, respectively. Conclusions Our findings demonstrate that uncorrected screening results may markedly overestimate the prevalence of physicians drinking problems.

Background Whereas urinary ethyl glucuronide (EtG) levels above 1,000 ng/ml reflect with a high probability ethanol (EtOH) consumption, levels below this cutoff are difficult to interpret as both extraneous (nonbeverage) EtOH exposure, recent drinking, and more distant high EtOH intake (several days ago) might yield similar results. This might be of particular relevance in medico-legal cases. To overcome this dilemma, phosphatidylethanol (PEth) might be a promising marker, because blood PEth is only positive following significant alcohol use. The aim of our study was therefore to employ PEth as a marker to differentiate between the different conditions. Methods Subjects included were 252 participants in monitoring with the Alabama Physician Health Program. All subjects testing positive for EtG and/or ethyl sulfate (EtS) who denied drinking after routine supportive confrontation were subject to information about PEth testing. If they still denied drinking, PEth testing was performed and the result communicated. EtG, EtS, and PEth testing was performed in a commercial laboratory using liquid chromatography tandem mass spectrometry methods. Results Of a total of 18 subjects who tested positive for EtG and/or EtS, 10 denied drinking. Of the 7 who denied drinking after PEth explanation, in 5 cases, their claim was supported by a negative PEth result. In 2 cases, a positive PEth result was in contrast to their claim. Conclusions PEth results in combination with previous low positive EtG/EtS results allow differentiating between innocent/extraneous exposure and drinking. Negative PEth testing following low positive EtG/EtS results helps to further elucidate the findings and support the claim of the patient of recent alcohol abstinence. Positive PEth testing following positive EtG/EtS results confirms recent drinking.

The success of the nation's state physician health programs (PHPs) provides important new evidence on the potential for dramatically reducing relapse and promoting long-term recovery from substance use disorders. This article summarizes the findings of the first national PHP study and outlines six lessons learned from this model of care management: (1) zero tolerance for any use of alcohol and other drugs; (2) thorough evaluation and patient-focused care; (3) prolonged, frequent random testing for both alcohol and other drugs; (4) effective use of leverage; (5) defining and managing relapses; and (6) the goal of lifelong recovery rooted in the 12-Step fellowships. PHPs are a part of a new paradigm of care management that includes the programs developed for commercial pilots (HIMS) and for attorneys (CoLAP). Elements of this model of care have been used with a dramatically different patient population, and with similar success, in the criminal justice system in HOPE Probation and 24/7 Sobriety. The authors review these programs and discuss implications for extending elements of the new paradigm more widely.

A high suicide risk has been reported among veterinarians in comparison to the general population. Postulated causes have included depression, substance abuse, work-related stress, reluctance to admit psychiatric problems, and access to lethal drugs and/or familiarity with euthanasia. Members of the Student Chapter of the American Veterinary Medical Association (AVMA), all veterinarians licensed in Alabama, and all US veterinary-association executive directors were surveyed regarding their attitudes concerning mental health issues, including veterinarian suicide. Only 10% of veterinary student respondents (N=58) believed that suicide risk is higher among veterinarians than in the general population. Of the 22 state associations' executive directors who participated in the survey, 37% believed that suicide is a significant concern for veterinarians and only 44% indicated that a veterinary wellness program was available in their respective states. Of the 1,455 licensed veterinarians in Alabama, 701 responded to the survey; 11% of respondents believed that suicide among veterinarians was a problem. In addition, 66% of respondents indicated that they had been “clinically depressed,” but 32% of those with depression had not sought treatment. More females (27%) than males (20%) admitted that they had “seriously considered suicide” (p

Background: A substantial proportion of therapists experience the loss of a patient to suicide at some point during their professional life. Aims: To assess (1) the impact of a patient’s suicide on therapists distress and well-being over time, (2) which factors contribute to the reaction, and (3) which subgroup might need special interventions in the aftermath of suicide. Methods: A 63-item questionnaire was sent to all 185 Psychiatric Clinics at General Hospitals in Germany. The emotional reaction of therapists to patient’s suicide was measured immediately, after 2 weeks, and after 6 months. Results: Three out of ten therapists suffer from severe distress after a patients’ suicide. The item “overall distress” immediately after the suicide predicts emotional reactions and changes in behavior. The emotional responses immediately after the suicide explained 43.5% of the variance of total distress in a regression analysis. Limitations: The retrospective nature of the study is its primary limitation. Conclusions: Our data suggest that identifying the severely distressed subgroup could be done using a visual analog scale for overall distress. As a consequence, more specific and intensified help could be provided to these professionals.

Heavy alcohol consumption may accelerate the progression of hepatitis C-related liver disease and/or limit efforts at antiviral treatment in opioid-dependent patients receiving heroin-assisted treatment (HAT). Our study aims to assess alcohol intake among HAT patients by self-reports compared to direct ethanol metabolites.Fifty-four patients in HAT were recruited from the centre for HAT at the University of Basel, Switzerland. The patients completed the Alcohol Use Disorder Identification Test (AUDIT), a self-report questionnaire on past-week ethanol intake and provided samples for the determination of ethyl glucuronide (UEtG) and ethyl sulphate (UEtS) in urine and of ethyl glucuronide (HEtG) in hair.Eighteen patients scored above the AUDIT cut-off levels. Twenty-six patients tested positive for UEtG and 29 for UEtS. HEtG identified ethanol intake of more than 20 g/d in 20 additional cases that did not appear in the AUDIT. Using the total score of the AUDIT, HEtG detected 14 additional cases of relevant alcohol intake.The findings of this study, which is the first assessing alcohol intake in HAT patients using direct ethanol metabolites and self reports, suggest the complementary use of both. Improved detection of hazardous or harmful alcohol consumption in the context of HCV and heroin dependence will allow for earlier intervention in this population. This ultimately will contribute to an improvement in quality of life of patients in HAT. Furthermore, a significant reduction of costs can be achieved through a reduction of complications caused by alcohol intake.

Physician Health Programs (PHPs) in the USA have evolved over the past 3 decades as models of recovery management. They encourage early referral, sophisticated evaluation, and active long-term monitoring and care management of troubled physicians, especially those with substance-related disorders. There are many benefits to these unique programs. Early detection of potentially impaired physicians not only protects patients but also saves physicians’ careers. Additionally, when addressing these problems clinically, rather than awaiting a crisis necessitating disciplinary action, complex and prolonged legal battles are avoided. PHPs safeguard both patients and physicians, and in the process they have developed one of the most successful models of recovery management. The strongest incentive for early referral is the opportunity for confidential care and advocacy for physicians who cooperate with their PHPs. PHPs have proven successful with reports of 5-year abstinence rates of 79%, return to work rates of 96%, and virtually no evidence of risk or harm to patients from participating physicians. Can the principles used by PHPs be transferred for use by other patients? Compared to other patients with addictions, physicians are an affluent and usually highly motivated group; however, there is evidence that their addictions are as severe as or worse as those of the general population. Certainly their access to drugs of abuse is greater than the general population. Many elements of PHP care management can be transferred, in whole or in part, to others offering the promise of substantial improvements in long-term outcomes.

BACKGROUND: Anesthesiologists have a higher rate of substance use disorders than other physicians, and their prognoses and advisability to return to anesthesiology practice after treatment remain controversial. Over the past 25 yr, physician health programs (PHPs), created under authority of state medical regulatory boards, have become primary resources for management and monitoring of physicians with substance abuse and other mental health disorders. METHODS: We conducted a 5-yr, longitudinal, cohort study involving 904 physicians consecutively admitted to 1 of 16 state PHPs between 1995 and 2001. This report analyzed a subset of the data involving the 102 anesthesiologists among the subjects and compared them with other physicians. The main outcome measures included relapse (defined as any unauthorized addictive substance use, including alcohol), return to anesthesiology practice, disciplinary actions, physician death, and patient harm. RESULTS: Anesthesiologists were significantly less likely to enroll in a PHP because of alcohol abuse (odds ratio [OR] 0.4 [confidence interval {CI}: 0.2-0.6], P < 0.001) and much more likely to enroll because of opioid abuse (OR 2.8 [CI: 1.7-4.4], P < 0.001). Anesthesiologists had a higher rate of IV drug use, 41% vs 10% (OR 6.3 [CI: 3.8-10.7], P < 0.001). During similar periods of monitoring, anesthesiologists received more drug tests, 101 vs 82 (mean difference = 19 [CI: 3-35], P = 0.02); however, anesthesiologists were less likely to fail at least one drug test during monitoring, 11% vs 23% (OR 0.4 [CI: 0.2-0.9], P = 0.02). There was no statistical difference among rates of program completion, disciplinary actions, return to practice, or deaths, and there was no report of significant patient harm from relapse in any record. CONCLUSIONS: Anesthesiologists in our sample treated and monitored for substance disorders under supervision of PHPs had excellent outcomes similar to other physicians, with no higher mortality, relapse rate, or disciplinary rate and no evidence in their records of patient harm. It is postulated that differences of study design account for contradictory conclusions from other reports.

Introduction: Physicians with substance use disorders receive care that is qualitatively different from and reputedly more effective than that offered to the general population, yet there has been no national study of this distinctive approach. To learn more about the national system of Physician Health Programs (PHPs) that manage the care of addicted physicians, we surveyed all 49 state PHP medical directors (86% responded) to characterize their treatment, support, and monitoring regimens. Results: PHPs do not provide substance abuse treatment. Under authority from state licensing boards, state laws, and contractual agreements, they promote early detection, assessment, evaluation, and referral to abstinence-oriented (usually) residential treatment for 60 to 90 days. This is followed by 12-step–oriented outpatient treatment. Physicians then receive randomly scheduled urine monitoring, with status reports issued to employers, insurers, and state licensing boards for (usually) 5 or more years. Outcomes are very positive, with only 22% of physicians testing positive at any time during the 5 years and 71% still licensed and employed at the 5-year point. Conclusion: Addicted physicians receive an intensity, duration, and quality of care that is rarely available in most standard addiction treatments: (a) intensive and prolonged residential and outpatient treatment, (b) 5 years of extended support and monitoring with significant consequences, and (c) involvement of family, colleagues, and employers in support and monitoring. Although not available to the general public now, several aspects of this continuing care model could be adapted and used for the

This article summarizes content proceedings of a symposium held at the 2004 Research Society on Alcoholism Scientific Annual Meeting in Vancouver, Canada. The chairs were Friedrich M. Wurst and Raye Litten. The presentations were (1) Introduction, by Raye Litten; (2) Direct Ethanol Metabolites--On the Threshold From Science to Routine Use, by Friedrich M. Wurst; (3) Sialic Acid Index of Plasma Apolipoprotein J (SIJ) as a Viable Marker for Chronic Alcohol Consumption, by Philippe Marmillot; (4) The Emergence of Ethyl Glucuronide (EtG) Testing as a Tool in Monitoring Healthcare Professionals, by Gregory E. Skipper; (5) Application of Biomarkers for Alcohol Use Disorders in Clinical Practice, by Tim Neumann; (6) Utility of Biomarkers in Assessing the Efficacy of Medications for Treating Alcoholism, by Marty Javors; and (7) Discussion, by Raye Litten.

Aims: Physicians recovering from substance-related disorders are usually allowed to return to practice if they agree to remain abstinent from drugs, including alcohol, and to undergo random urine testing. Over 9000 physicians are currently involved in such monitoring programs in the US. To date, it has been difficult to adequately monitor abstinence from alcohol due to the short half- life of alcohol and no other highly specific marker. Ethyl glucuronide (EtG), a direct metabolite of alcohol, offers an extended window for assessment of drinking status (up to 5 days). Our aim was to assess the potential value of EtG testing in abstinence-based monitoring programs. Patients and methods: Urine samples were obtained from 100 participants in a physician monitoring program and additional samples were subsequently obtained 'for cause', 'to verify positive urine alcohol, when drinking was denied' and 'in high risk individuals'. All participants had signed contracts agreeing to remain abstinent from mood-altering drugs, including alcohol, and had agreed to random urine testing. EtG was determined using LC/MS-MS in addition to standard testing. The main outcome measure were urine specimens positive for EtG versus those positive based on standard testing for alcohol and other drugs. Results: Among the initial 100 random samples collected, no sample was positive for alcohol using standard testing; however, seven were positive for EtG (0.5-196 mg/l), suggesting recent alcohol use. Subsequent EtG testing was performed clinically during the course of monitoring. Of the 18 tests performed to date, eight of eight tests performed 'for cause' were positive for EtG but negative for all other drugs including urine alcohol. All eight were confirmed positive by self reported drinking by the patient when confronted regarding the positive test result. Of six tests performed to 'confirm a positive urine alcohol' two were positive for EtG and confirmed positive by self reported drinking. For the other four samples, especially as two are from a diabetic, in vitro fermentation of ethanol is discussed. Conclusions: These data suggest that physicians in monitoring programs have a higher rate of unrecognized alcohol use than previously reported. Incorporation of EtG testing into alcohol abstinence monitoring can strengthen these programs.

Current biological state markers remain suboptimal with regard to sensitivity and specificity for monitoring recent alcohol consumption in various settings. Furthermore, these biomarkers can be influenced by age, gender and a variety of substances and non-alcohol-associated diseases and do not cover fully the time axis for alcohol intake. Ethyl glucuronide (EtG) is a non-volatile, water-soluble, stable, direct metabolite of ethanol that can be detected in various body fluids, tissues and hair. Shortly after the consumption even of small amounts of ethanol, EtG becomes positive. It can detect ethanol intake up to 80 hours after the complete elimination of alcohol from the body, covering a unique and important time spectrum for recent alcohol use. EtG seems to meet the need for a sensitive and specific marker to elucidate alcohol use not detected by standard testing.The literature was reviewed with a focus on possible diagnostic and therapeutic applications, currently available methods and future perspectives. To date, more than 4000 samples of body fluids, tissues and hair from approximately 1500 individuals have been assessed.The data suggest that EtG is a useful tool in numerous settings, including alcohol and drug treatment (to detect lapse/relapse and for motivational feedback), in safety sensitive work settings where use is dangerous or in other settings where alcohol use may be risky (e.g. such as driving, work-place, pregnancy or monitoring physicians or other professionals who are in recovery and working) or for resolving forensic questions. If the question of recent alcohol consumption has to be answered in a binary way (yes/no), such as for determining lapses. the use of EtG in urine is among the preferred tests. The use of this marker alone and complementary with other biological state markers and self-reports is expected to lead to significant improvement in treatment outcome, therapy efficacy and cost reduction.

Background: Considerable lives and money could be saved if one could detect early stages of lapsing/ relapsing behavior in addicted persons (e.g., in safety-sensitive workplaces) and could disclose harmful drinking in social drinkers. Due to the serious public health problem of alcohol use and abuse worldwide, markers of alcohol use have been sought. Both ethyl glucuronide (EtG) and phosphatidyl ethanol (PEth) appear to have high sensitivity and specificity and a time frame of detection that may elucidate alcohol use not detected by standard testing. Our aim was to assess their potential for detecting recent covert alcohol use under controlled conditions. Methods: Thirty-five forensic psychiatric inpatients in a closed ward who had committed a substancerelated offense (§64 StGB), were followed for 12 months. The complete time spectrum of possible alcohol consumption was covered by the complementary use of breath and urinary ethanol (hours), urinary EtG (days), %carbohydrate-deficient transferrin (CDT)/PEth (weeks), and -glutamyltranspeptidase (GGT)/ mean corpuscular volume (MCV) (weeks-months). Results: Fourteen of the 146 urine samples examined were positive for EtG. In all EtG-positive cases, patients reported alcohol consumption of between 40 and 200 g of ethanol 12– 60 hr prior to testing. Urinary and breath ethanol were positive in only one case. In the blood samples, PEth was not positive in any case and %CDT did not exceed the reference value. Isoelectric focusing showed no abnormal Tf subtypes. Conclusions: The findings emphasize the diagnostic and therapeutic usefulness, specificity, and sensitivity of EtG as a marker of recent alcohol use. Such a test is needed in numerous settings, including alcohol and drug treatment (to detect lapse/relapse), in safety-sensitive work settings where use is dangerous or in other settings where use may be inappropriate (e.g., such as driving, workplace, pregnancy, or monitoring physicians or other professionals who are in recovery and working), or for testing other groups (such as children or those with medical problems) where alcohol use would be unhealthy or unsafe. The health, social and socioeconomic benefits arising from the future use of these markers is hard to overestimate.

When a critical event occurs in most high-risk industries (such as airlines, nuclear power, or railways), a detailed investigation examines a variety of system and individual factors (such as fatigue and substance abuse) that caused or contributed to the event. Directly involved individuals are commonly tested for alcohol and other drugs. Airplane pilots and truck drivers are tested following crashes and near misses.1 Some law enforcement officers are tested following fatal shooting incidents.

To the Editor: The article by Berge et al1 entitled “Chemical Dependency and the Physician” contained little new information and several inaccuracies. First, contrary to the views of the authors who state “the problem of physician addiction has largely escaped the public's attention,” the public is fascinated with this subject. CNN recently reported on the closing of the California Diversion Program, US News and World Report published a survey regarding “Would you want to know if your doctor is addicted?” and during the past 20 years there have been repeated news upheavals and hysteria regarding this issue. The fascination by the public likely represents the incongruity of the mainstream view of addiction as a moral failure that affects lower class individuals and the image of the physician. Second, the section on intervention is misinformed. The authors suggest using a “confrontational approach, [wherein] the addict is faced by a roomful of family members, coworkers, supervisors, etc, who offer specific evidence of the addictive behavior….” In 28 years of working in the arena of physician health, I have performed thousands of interventions, and this type of “Johnson model” intervention is ill-advised, risky, more difficult to arrange, and less effective. In contrast, the most common model of intervention performed by Physician Health Programs (PHPs) is a nonconfrontational “professional intervention” model, in which evaluation is “strongly advised because concerns have arisen” without pressing the issue of whether or not there is a bona fide problem. Immediate discontinuation of work is recommended to avoid liability issues. If the physician considers refusing, he or she is gently advised that the alternative to the clinical (and usually confidential) approach of the PHPs is to refer the matter to the regulatory board. Prompt entry into the “safe harbor” of evaluation can be accomplished in the vast majority of cases without confrontation, thus avoiding the stress and attendant risk associated with confrontation. We frequently handle such interventions by telephone. In our series of 328 such interventions by telephone, there have been no differences in successful entry into evaluation and no deaths, compared with in-person intervention. Finally, the authors refer to the oft-repeated and likely faulty data published almost 2 decades ago by Menk et al,2 before advances gained by PHPs, in which 16% of relapses were associated with death. Articles that document highly successful treatment and long-term care of anesthesiologists were not mentioned.3-5 The article by Berge et al is well written but contains substantial misinformation. Involving a medical director of a PHP, an ultraspecialized area of medicine, who is on the front line of intervention and management of addicted physicians for future reviews would be optimal.